A review by health watchdog, the Care Quality Commission (CQC) has revealed “system-wide” problems in NHS investigations into patient deaths.
As a result, family members have been left in the dark about failures in care.
Around 5,500 patient deaths are investigated by the NHS each year, but the CQC stated that, in some cases, family and carer involvement was "tokenistic”.
If there is one thing this report highlights, it is the need to ensure that the process of investigating patient deaths is transparent and fully includes patients’ families.
One parent told the CQC: "I was put in a room. I shall never forget what the nurse in the room told me. She said, 'You have got to accept that his time has come. Bearing in mind my son was just 34 years old."
Investigations into deaths of patients with mental problems or learning difficulties were found to be particularly poor. These issues include a level of "acceptance and sense of inevitability" when people with a learning disability or mental illness died early.
The assessment was based on evidence from visits to 12 NHS trusts and a national survey of all NHS providers, including interviews with more than 100 families.
Sir Mike Richards, chief inspector of hospitals at the CQC, said: “We found that, too often, opportunities are being missed to learn from deaths so that action can be taken to stop the same mistakes happening again.
"Families and carers are not always properly involved in the investigations process or treated with the respect they deserve.”
Professor Dame Sue Bailey, chairwoman of the Academy of Medical Royal Colleges, said: "Put simply, we have consistently failed and continue to fail too many of the families of those who die whilst in our care.
"We must now ensure we rapidly put in place system-wide changes so that NHS trusts always treat families as equal partners in a consistent manner with humanity, honesty and common decency when deaths occur."
Ian Cohen, a clinical negligence specialist at Slater and Gordon, said: “A number of initiatives have been introduced to help the NHS to improve its investigations most recently with the statutory Duty of Candour, but tragically we still see the same issues and mistakes being repeated time and time again.
“We are currently involved in a consultation process with the Department of Health with regards to introducing a ‘Safe Space’ in the NHS as part of the Healthcare Safety Investigations Branch (HSIB).
“If there is one thing this report highlights, it is the need to ensure that the process of investigating patient deaths is transparent and fully includes patients’ families.”